- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,312.77 / $1,400.00 / $2,001.06
| Facility | | $1,312.77 | $1,400.00 | $2,001.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.25 / $1,312.77 / $1,574.46
| Professional | | $1,113.25 | $1,312.77 | $1,574.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,359.49 / $1,549.67 / $1,688.39
| Facility | | $1,359.49 | $1,549.67 | $1,688.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.89 / $1,500.79 / $1,500.79
| Professional | | $769.89 | $1,500.79 | $1,500.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.76 / $1,455.76 / $1,455.76
| Facility | | $1,455.76 | $1,455.76 | $1,455.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.33 / $1,750.92 / $3,609.06
| Professional | | $1,127.33 | $1,750.92 | $3,609.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.45 / $1,367.98 / $2,070.75
| Professional | | $998.45 | $1,367.98 | $2,070.75 |